Divisional Head of Nursing, Lead Cancer Nurse Head of Patient Involvement & Volunteering. Item Subject Action

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1 King s College Hospital NHS Foundation Trust Board of Directors - PUBLIC Minutes of the meeting of the Board of Directors held at 09:30 on Tuesday, 02 February 2016 in the Dulwich Room, Hambledon Wing, King's College Hospital, Denmark Hill site Members: Lord Kerslake (BK) Sue Slipman (SS) Chris Stooke (CS) Faith Boardman (FB) Prof. Ghulam Mufti (GM1) Prof. Jon Cohen Dr Alix Pryde (AP) Erik Nordkamp (EN) Nick Moberly (NM) Dawn Brodrick (DB) Alan Goldsman (AG) Non-voting Director Ahmad Toumadj (AT) Non-voting Director Jeremy Tozer (JT) Geraldine Walters (GW) In attendance: Tamara Cowan (TC) Paul Donohoe (PD) Anne Duffy (AD) Jessica Bush (JB) Fiona Clark (FC) Tim Bradley Jan Thomas Andy Simmons Homa Arshad Apologies: Julia Wendon (JW prior to Feb 2016 ref JW1) Sally Lingard (SL) Judith Seddon (JS) Non-voting Director Trudi Kemp (TK) Non-voting Director Steve Leivers (SL1) Non-voting Director Trust Chair Non-Executive Director, Vice Chair Non-Executive Director Non-Executive Director (part) Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Acting Chief Executive Officer Director of Workforce Development Interim Chief Financial Officer Interim Director of Capital, Estates & Facilities Interim Chief Operating Officer Director of Nursing & Midwifery Board Secretary (Minutes) Assistant Medical Director Divisional Head of Nursing, Lead Cancer Nurse Head of Patient Involvement & Volunteering Public Governor Public Governor Patient Governor Southwark Council Consultant Applicant, KCH Medical Director Associate Director of Communications Acting Director of Corporate Affairs Director of Strategic Development Director of Transformation & Turnaround Item Subject Action 16/1 Apologies Apologies for absence were noted. The Chair also welcomed EN and CG to their first meeting of the Board of Directors. 16/2 Declarations of Interest There were no declarations of interest reported. 1

2 16/3 Chair s Action There were no Chair s actions to report. 16/4 Minutes of Previous Meeting The minutes of the meeting held on 15 December 2015 was approved as a correct record. 16/5 Matters Arising/Action Tracking The action tracker was noted and there were no matters arising since the last meeting raised for discussion. 16/6 Patient Story Anne Duffy presented to the Board the story of a patient using the Chartwell Unit. The Chartwell Unit provides local cancer service to the people of Bromley and the surrounding area. Patients undergo assessment, diagnosis and possible treatment for cancer including malignant and non-malignant haemato-oncology patients, oncology patients and palliative care patients. The following key points were highlighted from the patient s story: The Trust is not very good a looking at patient s lifestyle when choosing a course of action; Lack of effective leadership was a big issue in addition to staff not engaging with patients who have long-term care sessions. There has been a review of the leadership, which is being addressed, and operational changes implemented and subject to annual review with nurses. The patient environment needed significant improvement which has now been completed; and There needed to breast service nurses available at the beginning and end of the day which is now in place. The Board raised the following key points in discussion: The story is valuable and it is evident that this particular patient is well informed coming from a nursing background. However most patients do not know the interplay between chemist and GPS is not good therefore the Trust needs to close the gap for the lay patient; As part of the work to improve the operational function in the Unit the Trust consulted with lay patients and accordingly has standardised conversation with patients; Other means of feedback have also been used to drive conversations with patients and the Trust is looking into developing a booklet to support key conversations with patients; 2

3 Introductions to peer groups are also valuable and can provide additional support to patients. The Trust does have a Breast Support Group at the Princess Royal University Hospital (PRUH) site; Core is communication. There is lots of fascinating research on how communication is key in any patient care pathway. Accordingly the Trust has to look at this case and work with nurses colleagues to improve patient experience; Whilst the Trust uses all patient stories in nurse training it is evident that more could be done to improve engagement with patients and work is underway to develop simulation training using mind and body methodologies; There had previously been discussions about expanding the capacity to host mental health patients with SLaM but these did not reach fruition; Through competency performance management and verbal redress the Trust is dealing with insistent professionals ; The connection with employees and patients should be used as engagement and discussion tools to make changes necessary; The Trust is also using value based standards, results from national cancer surveys and local resources such as how are we doing results, divisional scorecards to support targeted training; The patient story is very powerful and it is positive that the Trust made some valuable changes to the system and design of the service. As part of the emerging strategic vision, which implies brilliant outcomes, this is at the heart of how the Trust transform its services namely through listening to patients feedback taking a systemic approach to changing services whilst holding people to account; Oncologist come from the Cancer Centre therefore patients in the Chartwell Unit sees the same consultants through their pathway; and It is evident that there is a strong interdependency on open two-way communication and the leadership has to be at the front and centre of applying this model. 16/7 Chief Executive's Report The Board received and noted the report from the chief executive officer (CEO). The following key points were reported: It is time to start the dialogue with the organisation about positive and optimistic view of the organisation; 3

4 The financial issues last year dented the confidence to the organisation so it is time to communicate that the Trust is getting to grips on the finances and operations despite there being lots more to do. The Trust is moving towards the future by undertaking a consistent evidence based transformation programme to improve processes and embed best practice. The next steps also including getting the Trust to long-term sustainability and ensuring services are delivered in a sensible ways to support high quality and utilising the KHP dimension; The Trust is on a journey to sustainable excellence through renewal of the Denmark Hill site and it is time to promote this in a vigorous way; and These messages have to be sent out to the organisation to promote confidence that the tanker is turning and the longer-term vision is about sustainability. In discussion the Board raised the following key points: It is acknowledged that people feel stretched and in some cases it is hard to see beyond the here and now; The key challenge lay with institutionalising close financial control rather that the current project approach. It is time to make strong financial controls apart of the culture of the Trust; The Trust is required to submit an operational plan to Monitor and as part of the new sustainability and transformation plans (STP) the Trust will work with its South East London (SEL) partners to develop a long-range sectorial plan that speaks to genuine sustainability across the sector. The plan will support the NHS moving to a more integrated organisational approach. Our Healthier South East London (OHSEL) will lead the development of the plan and will be the vehicle to generate the transformation plan, which the Trust will have to play a key role; It is good to see that the system is finally moving to a sectorial approach to developing sustainable plans. There is only so much, which is in the control of the Trust, and it relies on others delivering their part in order to succeed in its plan. It would also be useful to understand what role NHS England (NHSE) will play in ensuring all parties achieve their deliverables; This year the Trust has received very good local commissioner support and work continues on those relationships; NHSE is developing a new dashboard to look at performance across the sector. This approach is new to commissioners who are not used to this level of system performance management; 4

5 The Better Care Fund (BCF) is still available and separate from the Sustainable and Transformation Fund. NHS processes are not very cohesive at present and there are clear tensions between a high cost system and low experience base. The Trust must see how it can get access to the BCF and other means of securing other funding. Development of sectorial plans is a clear way for healthcare organisations to take control of their own destinies; It is not so much about what NHSE can do for the Trust it is about what the local partners can do for themselves and how they hold each other to account; and Given that 1.7bn has been pledged to the acute sector and in SEL there are 6 clinical commissioning groups (CCG) the Trust must be part of the sector leadership. 16/8 IMPROVING QUALITY OF CARE FOR PATIENTS 16/8.1 Quarterly Patient Outcomes Report The Board received the quarterly patient outcomes report. It was reported that the Trust has been rated green (positive) for 22 indicators, yellow (neutral) for 22 indicators, and has 2 red rating against the national hip fracture clinical audit. The Board noted that the Trust made changes to the hip fracture pathway which has reaped improvement in the mortality ratings and performance against the 9 best practice standards. 16/8.2 Adult Safeguarding Report The Board received and discussed the adult safeguarding report. The following key points were reported: Deprivation of liberty (DoLs) safeguards processes have changed during the reporting period which may result in more DoLs; When the Trust raises a DoLs application it can take at least two weeks to go through the system by which time the need to deprive said person of their liberty has passed; The Trust is not complying with adult safeguarding training requirements; and There has been one coroner case and three case reviews. The Board raised the following key points in discussion: The process for DoLs does not seem sufficiently streamlined with staff seemingly getting caught up in bureaucracy; 5

6 The number of DoLs referrals (584) seems very high which begs the question about whether or not the staff responsible for completing these applications is at the right level of seniority; It would also be useful to understand what other organisations are doing; The safeguarding team provides advise on each DoLs referral; There needs to be collaboration with the system to make sure the process is robust and meaningful; The Trust also needs to understand if there is a better process being used elsewhere. It was agreed that the Trust would look at DoLs benchmarking data across the Shelford Group and get some qualitative data about the process being used elsewhere. GW 16/8.3 Children Safeguarding Report The Board received and discussed the children safeguarding report. The following key points were reported: The Trust is at relatively high risk for children safeguarding issues given its locality, attributable trauma function and high levels of activity; Whilst the Care Quality Commission did not assign any must do actions in relation to the child safeguarding service there were some should do actions. These include improving child safeguarding level 3 training in A&E, increased scrutiny of outsources services in regard to Section 11 Report requirements. The Trust has taken action to address these should do actions as detailed in the report and training numbers have improved over the last year; The Trust is also taking forward the learning points from managerial review and big steps are being taken to improve information sharing in the system; and Local safeguarding boards also want to improve data collection. The Board raised the following key points in discussion: The safeguarding team in Bromley has been strengthened; There is an issue with the system for collecting data on staff training and a business case will be presented to BRSG for a new system; and The reviews into child deaths are conducted centrally and this is done centrally. It was agreed that a progress report on the safeguarding training and the implementation of the new system would be presented to the Board in 6 months. DB/GW 6

7 16/8.4 Trust Quality Priorities 2015/16 The Board received and noted the update on the quality priorities. The following key points were reported: The Trust, in conjunction with key stakeholders including governor identified 6 priorities to give internal focus in 2015/16, some of which were linked to major internal projects: Patient outcomes domain - smoking and alcohol cessation and hip fracture outcomes improvement; Patient safety domain - surgical safety and medication safety; and Patient experience domain - improving cancer services and discharge process; The progress on each of the priories has been mixed with most of the objectives in progress; and The Trust has also identified a long list of priorities for 2016/17 which will be sent to stakeholders for their input. The Board raised the following key points in discussion: There is a Trust wide issue about data. The internal auditors raised concerns from the data that they audited; Never events are a big issue for the Trust therefore, it is being proposed that focus should remain in this area for 2016/17. Whilst there have been some improvements it is not in the bag; It is also feasible that at some point these priority areas of focus will move into more transformational workstreams; It may be worthwhile the Trust investigating what was done in Leicester Hospital who invested in an initiative which not only improved safety but also saved money; There is a question of whether or not the Trust needs to choose 6 priorities. It may be better to choose fewer areas to give focus and put all energies and efforts in; and It is also important to ensure that both qualitative and quantitative measures are aligned to chosen priorities to enable effective analysis. The Board agreed to the broad approach subject to consideration being given to the comments above and that the issues with data usage are investigated. 7

8 16/9 DELIVER THE FINANCIAL PLAN 16/9.1 Finance Report (M9) The Board received and discussed the month 9 finance report which was also discussed at the Finance & Performance Committee meeting held on 26 January The following key points were reported and raised in discussion: At month 9 the Trust has a 71.9m deficit against a planned year-end deficit of 65. The Trust however have some mitigation plans to get back to plan which is expected to reap circa 20m; It is vital that the Trust delivers the plan and it is equally important to deliver the CIPs; Cashflow is also very tight; The Finance & Performance Committee considered this and the risk of not making the expected improvement in run rate. Delivering against forecast over the last 3 months of the financial year is even more important; The Trust needs to be close to the target it set at the beginning of the year; The Trust needs to remain focus especially in areas where the Trust has underperformed; The Trust has brought forward disputes about specialist activity with commissioners and these have largely been resolved; NHS England works two months in arrears and do no acknowledge transactional care. The Trust is still working on getting commissioners to reinvest fines and penalties; The Trust is two months away from running out of cash and action should be taken to address this immediately; and There has been some improvement on the medical agency CIPs but the improvement has been slow. 16/10 MOVING TO OPERATIONAL SUSTAINABILITY 16/10.1 Performance Report (M9) The Board received and discussed the month 9 performance report which was also discussed at the Finance & Performance Committee meeting held on 26 January

9 The following key points were reported and noted: There has been solid performance in cancer and all cancer targets have been met in the last two consecutive quarter. There is however a big risk with urology pathway with some very long waiters; Referral to treatment (RTT) validation has been completed. The Trust is working through the list of 52 week waiters with 169 inpatients and 104 non-admitted; There is a robust governance process in place with regular updates at the King s Executive meetings; and The Medical Director also meets with clinical commissioners to conduct rout cause analysis of the patients on the lists and it can be confirmed that no serious harm has been identified to patients on the list. The Board raised the following key points in discussion: There have been no deaths at 52-weeks patients and this information is yet to be validated for patients waiting 30 weeks; It is possible that once some long waiters have been treated it will come to light that there has been some harm as a result of the delay; The emergency departments at the Denmark Hill (DH) and Princess Royal University Hospital (PRUH) have differentiation in cohort of patients; The DH site is over performance and PRUH is under performance; The Acute Care Hub at the DH site opened in the Matthew Whiting ward which was filled to capacity; There are some cross cutting themes being looked at to improve capacity and the Trust aspires to move ahead; Local commissioners know that capacity is an issue on the DH site but it goes beyond more beds; There has been very good improvement at the PRUH site but the Trust has not managed to sustain drop in occupancy levels to get new hospital processes fully embedded; Despite the synergies achieved in the discharge unit there are still issues with the amount of people in beds; Although the structure of the PRUH pathway looks right the Trust really needs to drive and unpick the data at an operational level; At the DH site there is significant pressure on the speciality beds for example in cardiology, neurosciences and haematology which is also resulting in financial implications; 9

10 The Trust has 34 beds short and there tertiary service is swelling all the time; Commissioners supported the Trust during Pulling Together Week but it is not feasible for them to continue to provide this level of support all the time; The performance of 7% against the national 1% trajectory for 6-week diagnostic waits is disappointing. This was as a result of issues over the December period and the Trust is now working on aligning all equipment; and The performance against c.diff trajectory seems to be going in the wrong direction. The Trust is two ahead where it should be at the DH site and the PRUH is below trajectory. The root of addressing the infection control issues lay with deep cleaning and fumigating sites. This would call for closing capacity in already stretched resources. In the interim regular cleaning audits are being taken place and the infection control teams are providing additional support across the Trust. It was agreed that 6-weeks diagnostic waits would be a deep dive at the Finance & Performance Committee. FPC 16/10.2 Nursing Revalidation Report The Board received the recast monthly nurse staffing report.. The following key points were reported: The use of Healthcare assistants (HCAs) has come down in year at both the acute sites; There was overstaffing on the Sam Oron ward were 3 instead of the two members of staff were used to support an agitated patient; and There were also a number of instances of staffing levels being lower than 83% but this was within tolerance levels. In discussion the Board raised the following key points: The Trust uses HCA to cover shifts when there are not enough nurses and the ward requires additional resources. In addition before foreign nurses receive their pin from the Royal College of Nurse they are categorised as HCAs; The turnover of band 5 nurses is high creating a vacancy hotspot. The turnover is 92.5%. This I similar to other organisations; From leavers feedback it is evident that key reasons for leaving the Trust are issues with work-life balance and pay; The Trust is working with a task and finish group to look at the issues in partnership with Guy s & St Thomas ; 10

11 The Trust is developing clear recruitment plans with focus on critical care nurse hotspots; Further work on branding strategy to attract more nurses is required. The Trust is also hosting targeted recruitment events. The Trust also needs to engage in active career path management and this will be included in the recruitment plan for 16/17; There is a long lead in time for getting foreign nurses, 9 months, fully trained and in receipt of their necessary documentation whilst European nurses is only 2 months; There is a system-wide shortage of nurses. Effective forward planning will help the Trust get ahead of the game; and It will be useful to see data on the number of patients in each speciality to provide further clarity on trends. It would also be useful to include in the report the current vacancy rates. 16/11 UPDATES FROM BOARD COMMITTEE AND COUNCIL 16/11.1 Board Committee Updates 16/ Quality & Governance Committee (QGC) GM advises that QGC met on 14 January The Committee conducted two deep dives into SHMI and imobile. Both presentations highlighted some key areas of improvement in the Trust in particular the impact the imobile services is having on the patient pathways. The Committee was however concerned about the safeguarding training as mentioned above. 16/ Finance & Performance Committee (FPC) CS advised that FPC met on 26 January and looked at the draft financial plan for 16/17 and the sustainable transformation plan which will be discussed at the private Board. The Committee will also be conducting deep dives on key performance and finance related topics in the coming months. 16/ Education & Workforce Development Committee (EWDC) FB advised that EWDC met on 26 January. The Committee has begun exploring workforce landscape at a strategic level taking into consideration how it fits in with the wider Trust strategy. There has been good progress in developing meaningful KPIs that will also include training. 16/ Audit Committee (AC) AP advised that AC met on 26 January The Committee discussed the pending external and internal audit tender process. AP, CG, CS along with three governors will form the panel for appointing the external auditors. The Committee looked at audit reports on the recruitment, CIPs, coding and data quality. 11

12 16/11.2 Council of Governors Activities The Board noted the following update on Council of Governors activities from Fiona Clark, Public Governor and Chair of Governor Membership & Community Engagement Sub-committee: Governors had a good workshop where the main topic of discussion being discharged which also featured Cathy Ingram who looks after community services at Guy s & St Thomas. The workshop was informative providing sufficient time for governors to understand the role of the transfer of care bureau and how the different teams work together; The governors also started observing the some of the other Board committees this year to enable governors to have more visibility of non-executive directors in action; and Governors are very concerned about the financial position of the Trust but are equally anxious if not more so about the morale of staff. Staff have been approaching governors and expressing how stress they feel and about job security in the current climate. There is an unhappy undercurrent running through the organisation governors would like to see addressed immediately. 16/12 FOR INFORMATION 16/12.1 Monitor Quarterly Submission The Board noted the Trust quarter 3 submission to Monitor which was approved by the Finance & Performance Committee. 16/12.2 Chair's and Non-Executive Director's (NEDs) Activity Report The Board noted the report on the Chair and NED's activity. 16/12.3 Confirmed Board Committee Minutes The Board noted and received the confirmed minutes of the Finance & Performance Committee held on 24 November and 15 December /13 ANY OTHER BUSINESS There were no matters of any other business raised for discussion. 16/14 DATE OF NEXT MEETING Tuesday, 01 March 2016, 09:30 at the Demark Hill site 12